History of the development of UTHSCSA

There is an adage that states that we should be careful what we wish
for as we may get it. In many respects it applies to our school.
Another that states that it is easier to start a tradition then to
maintain it does not apply. The creation of this school was not easy
and its 1st five years and saw a good deal of turmoil. That the
community got what it expected was certainly not evident.

San Antonio was founded nearly one hundred twenty years before
Galveston and had endured much history by 1881. In that year, the
University of Texas was established and concurrently the first
University of Texas Medical School was approved and sited by a state
wide referendum for Galveston by over 70% of thirty thousand votes cast.
Associated with the establishment of this school, the University
assumed much responsibility for the John Sealy Hospital as a teaching
institution. At that time, Galveston had a medical society, two private
medical colleges and had seen the first medical journal in the state
(The Galveston Medical Journal - 1866-1871). San Antonio, although
growing rapidly, had a number of real basic health issues: lack of a
good sewer system, lack of control of tuberculosis, an uncontrolled
advent of pulmonary patients coming to the area and no real public
health system. It was a frontier town.

The Spanish American and two world wars would pass before effective
efforts to establish a medical school here would be mounted. In 1906,
Galveston was virtually destroyed by a hurricane and tidal surge which
claimed more then 6,000 lives. It is hard not to believe that this
event and the ensuing recovery prompted many of the proposals to move
the medical school to San Antonio. The activity was sporadic and
definitively squashed in 1944. Early in the 1940's, attempts to
establish a medical school here began to coalesce, but the road was to
prove long and hard. In the mid 1940's the San Antonio Medical
Foundation was organized and it gradually assumed the leadership in this
activity for the community.

In the 1940's & 1950's many bills were introduced in the Texas
Legislature for a variety of public health projects; none were funded.
Bills for a San Antonio medical school were introduced 1947 and 1949.
The latter was definitively trumped by an offer from Dallas in 1949 to
the regents of the University to back a proposal for the University to
take over and operate a small private medical college. This school has
become the justly famous University of Texas Southwestern Medical
School. It was the second University medical school. I am certain that
the backing of the city of Dallas was essential to this action since the
University did not wish to engage itself in sponsoring or paying for
another major hospital. The action effectively moved the chances for
San Antonio back by a least a decade.

From the mid 1940's much of the activity to procure a medical school
was in the hands of the San Antonio Medical Foundation. Basically, it
was a group of visionary, astute individuals, who were also very good
businessmen; many were physicians. It is a non profit organization with
stated goals of medical, charitable, and educational purposes. The
principal spokesman was Dr. John M Smith Jr. a prominent local general
practitioner and an experienced medical politician. He was a very vocal
proponent for the school and an effective force in national medical
politics; he was also a warm and friendly across the street neighbor of
ours for more then thirty years. This group quietly acquired farmland
northwest of San Antonio, at some distance from the downtown area, when
such property was available and cheap.

Between 1920 and 1940, the population of San Antonio had doubled to
400,000; by 1950 it was to increase by another 25% to nearly 500,000.
From 1945-1960, many proposals to establish a school were raised and
discarded. What was really important and indicative of the vision of
the medical foundation, was the process of urban change. A coalescence
of forces occurred that made San Antonio a major metropolitan area not
only capable of supporting such a venture but actually needing it.

In January 1959 the Bexar county legislative delegation was
instructed to introduce a bill in the Texas House to establish a
University of Texas Medical School in their county. The bill passed the
House and was approved in the senate with a codicil deal that stated, 'An
appropriate teaching hospital be located within one mile of the campus
of said school'. The proviso was added by a senator from Dallas who
anticipated tepid local support and knew that the University wanted no
part of maintaining a teaching hospital as it had been obligated to do
for many years in Galveston. Thus, after six decades of consideration
and fifteen years of active effort, the long and often contentious trek
to procuring a school was ended successfully. It was by no means the
end of issues.

The first major one, since the initial consideration of a school,
had been its site. As might be expected in Texas, at least two contrary
views arose: downtown or outside the city. There were vocal adherents
on either side. The issue was decided fairly promptly, if not amicably,
by the donation to the university from the medical foundation of 100
acres of its land for a site northwest of the city in open territory
allowing growth and development. This site, bitterly opposed by
advocates of a downtown campus closer to the patients, has proven
visionary indeed and has allowed remarkable growth. Our school is the
largest health science center in the University system; and still, after
nearly 5 decades, has room to grow. The centers in Dallas and Houston,
at their inceptions were entirely surrounded by urban development and
really could only grow up. Aside from land owned by the University, the
foundation still controls some 150 to 200 acres of undeveloped land in
the medical center complex. Certainly, for those initially involved,
this is a classic case of doing well by doing good. The decision cost
the school and hospital the support of one of the major fortunes of the
city, and remnants of the split have persisted for some time.

The Robert B Green hospital was built and opened in San Antonio in
1917. It served the charitable medical needs of the community until the
early 1950's. It is to be noted that the population of the city
increased by 150% in those 30 years and relatively little if anything
was done to upgrade the hospital. It closed, probably for fiscal
reasons, in the early 1950's and was reopened with some refurbishing in
1955 under the aegis of the Bexar County Hospital district, a brand new
taxing and funding agency. It was the first such district in the state.
The hospital remains under this administration today, an exclusively
Bexar County responsibility, taking a large percent of the annual
property tax levied in the county.

The first dean of the school was Dr. Robert C. Berson who came in
April 1962 and did little except to establish an office in two rooms of
the National Bank of Commerce building and to hire Mary Ann White as his
secretary. He is credited with identifying needs and establishing some
sort of presence. He was hampered by lack of legislative response or
significant funding. His resignation in October 1964 made way for the
2nd, and, to many, the most effective leader this school has ever had.
Dr. F. Carter Pannill had been an assistant professor of medicine at the
University of Texas Southwestern in Dallas and Assistant Dean for Grants
Management. He is credited with getting the buildings built and
gathering the initial faculty, starting some five years after the school
was created.

Construction on the school and hospital started concurrently in the
mid 1960's, the former funded by the state, the latter, by the county.
It was one of the few instances in American medical history that a
hospital and its associated school had been built together as an
architectural unity. Progress was well along by December 1966; more
then 30 faculty and some chairs had been recruited, and construction was
proceeding apace. In January 1967, a uniquely Texan situation arose.
Bexar county voters had enthusiastically endorsed a five million dollar
bond issue to build a new teaching hospital. This sum was matched on a
3 to 1 basis by federal Hill-Burton funds. County planners in 1967
realized that, if they owned the hospital, they had to pay for it
annually and they had hopelessly underestimated its cost. There were no
county funds for it. Officials in the county were allowed to tax $0.75
on each 100 dollars of property value and property values were capped at
25% of the real market value. The obvious solution, to tax for the
hospital district at a higher rate of market value (up to 50%), was
presented as a general referendum in January 1967 and was overwhelming
rejected by the voting public.

The resulting brouhaha involved almost everybody: the archdiocese,
the military base commanders, the commissioners, and the citizenry. In
March 1967, an appeal was made to the Bexar County legislative
delegation to present a resolution to allow the expanded taxation. The
bill passed the house and the senate and authorized the county
commissioners in Dallas and Bexar County to tax up to 50% of the real
market value for hospital district funds. Three courageous county
commissioners led by presiding Judge, Blair Reeves and including James
Helland and O.E. Wurzbach voted for the raise. Two commissioners
opposed the action. Hospital construction could proceed with some
guarantee now of annual funding.

In the 1st year of operation, the hospital funded a budget of 16
million dollars and incurred a deficit of 1 million which cost the
director his job. This budget has grown to nearly 600 million dollars
of which approximately 25% is covered by hospital district taxes.

Over more then three and one half decades, the investment of the San
Antonio Medical Foundation of 100 acres of land has provided a handsome
return. In 2004, the chamber of commerce cited the school as a major
dynamo in a health care industry of 1.5 billion dollars annually. What
was undeveloped farm land in the 1950's is now entirely surrounded by
San Antonio growing northwest and northeast. Thanks to a good bit of
vision space still exists after over 40 years for new projects and
expansion.

In the early 1960's, San Antonio was a parochial town lacking much
medical sophistication. Medical practice was dominated by the general
practitioner; referrals were among close friends within given cadres;
and board certification was not common. Only a very few decades
separated the community from the first major Texas medical practice act
(licensure to practice). Practice was unregulated and largely
independent. The introduction of a medical school into such a
community was no insignificant event. There is no lack of evidence that
many individuals in this professional community had worked and schemed
diligently for years to achieve the establishment of a medical school.
There is also no lack of evidence that what so many had worked for was
not what they had expected nor what they got.

Probably the first realization was that faculty recruitment would
take place. Members of the medical community would not automatically be
appointed to a faculty position with an appropriate title and stipend.
Certainly this revelation engendered some righteous indignation. The
second concept that came with the school was that of the closed staff
hospital (board certification required). It takes very little
imagination indeed to envisage the reaction of practitioners upon
finding out that they were not even eligible to apply to practice in
their new hospital built with a county bond issue, and supported by
county taxes and designed to match the architecture of the school.
Rapidly, indignation became downright hostility of a very ardent nature.

This situation was not ameliorated at all by the first chair of the
combined departments of Medicine and Physiology. Eastern coast,
arrogant, bright, brash and thoughtlessly outspoken, he allowed himself
to be quoted widely in the press concerning his opinion of charitable
services available in San Antonio and the level of health care in
general. No opinion that he gave was favorable to the community and
each one had an implication that the school would soon correct a real or
an imagined flaw. The fact that much of this disparaged care had been
given pro-bono by a great number of the readers of the press was lost on
him. The fact, as Dr. Pruitt has observed to me, that he may have been
right, was lost on the community in general; the talk fostered a
considerable amount of hostility and continued unabated for some time.

This same chairperson was a jealous guardian of turf and one of his
divisions become a front line for an in-house war. Early, on, by some
chance, the Department of Pathology had hired a team of three
hematologists which provided, to my mind to and those of all the other
surgeons, the best hematological service we have ever seen. Consultants
came to the OR on demand and solved problems quickly and definitely.
The comparable group in Medicine was largely theoretical, hands off, and
on a routine delayed consult basis. We regarded them as useless and
incompetent. Another aspect of the matter was that the Department of
Medicine held that no one in the Department of Pathology had a right to
see clinical patients.

In 1972, a major debacle combined this internecine war within the
faculty with the town-grown hostility that has been developing for four
years. The regents demanded action, the chairs required some direction
and faculty polarization was intense. When all was over, the chair in
Medicine was fired, the chair in Pathology was relieved of his post but
remained on the faculty, well over one half the members of each
department resigned and the dean who had remained loyal to the medicine
chair felt he had no choice but to leave. This event, barely 3 years
after the school had accepted its first students, was a major and near
fatal catastrophe largely of our own making and one from which few
institutions could recover. The individual selected by the University
to deal with the problem was a huge figure both physically and
professionally - a noted Plastic Surgeon from Galveston Dr. Truman
Blocker. He owned a massive reputation and physical habitus and
projected a great aura of stability. Nevertheless, the result of this
disagreement was the perception by the medical community of the school
as a competitor for compensated patients; and, thus, a natural enemy.
Faculty status was a flat reason to deny hospital privileges anywhere.
Four decades have had to pass before much of this feeling eased.

This event also marked a major milestone for the school. In 1972,
the school together with the dental school which had been founded in
1969 was denominated a health science center. A nursing school, an
Allied Health School and a Faculty of Biomedical Science's (basic) were
shortly added; a president, Dr. Frank Harrison was named. Two other
presidents have succeeded him, Dr. John Howe, and Dr. Francisco
Cigarroa. The purview of the school now extends to the Rio Grande
Valley and includes centers for Pediatrics and Cancer patients.
Building has added much new administrative and educational space. The
hospital also has come into the 21st century and has at least eight
satellite clinics. The whole has become the largest Health Science
Center in the University of Texas System.

At least two other major storms remained for this school to weather,
one was of our own making and one was where our reactions were
questionable.

In the fall of 1982 two faculty members, a pediatric neurologist and
Dr. Kent Trinkle our Senior Cardio-Thoracic surgeon, each noted
anomalies in our Pediatric Intensive Care unit. Children admitted for
neurological care with no known pulmonary problems and routine post
operative chest patients also without such problems were experiencing a
disturbing number of unexplained pulmonary or cardiac arrests requiring
major resuscitation.

While this was disturbing, no one in the unit
died. At that time, Pediatrics was chaired by a weak interim head. The
pediatric intensive care unit was under the direction of single faculty
member who attempted to provide care for each patient by himself. The
problem continued; and three in-house investigations were carried out
through November and December 1982 and January and February 1983 to no
particular end or resolution. It was a fairly open secret that one
individual in the unit was a focus of suspicion. She was an LVN with an
unblemished record of excellent reviews. The last in-house review
recommended that the unit be closed and the patients be transferred to
the surgical intensive care unit which I directed at the time. This
suggestion, on some scrutiny, would have proved to be disastrous.
Ultimately the dean and the director of the hospital requested me to
form a committee from three departments to oversee the unit and to
accept a suggestion to transfer the unit to an all RN one. It was a
typical administrative decision, not addressing the basic issue but
removing the nurse in question.

The following July a graduating pediatric resident, against violent
advice to the contrary, offered the nurse a position in a new private
office she was setting up in Kerrville. At the end of August, in that
office, catering to well babies for check ups, shots, and routine
pediatric problems, there had been three instances of unexplained
pulmonary arrest. No such instance had occurred in
Kerrville in the previous 50 years. One of these three instances was
fatal. In February 1984 the nurse was convicted of injecting babies
with muscle relaxants and jailed, where she remains today.

Two years later, in 1985, this nurse was traced to the University
Hospital; and a crusade, led by a politically ambitious district
attorney and a singularly ill informed San Antonio Express-News writer,
crucified the hospital and school. A grand jury was impaneled; the FBI
was involved and six months of great distress ensued. No one in the
hospital or school was ever indicted, and the oversight committee lasted
for the next 10 years.

In the mid 1990's, another school-wide crisis arose. At a time when
overall patient income was dropping, the university enforced a
regulation that all patient collections hitherto done at a department
level be centralized. Such a move is predictably disastrous for
individual departments because much is lost to them. At about the same
time, a disgruntled former director of our collection service 'blew the
whistle' on our school in terms of collections that had been received
from the government that were not properly documented.

In the light of
current government regulations, any service not documented in a
satisfactory form has not been given and thus any such money collected
is fraudulently acquired. The school was initially accused of taking
some $80,000,000 in this manner. A final figure required us to pay back
$17,000,000. This drop, of course raises the legitimacy of the claim in
the first place. Much of this problem came from our own arrogance in
disdaining clearly defined rules for accepting government money. The
burden on the school lasted 5 years and fell significantly on surgery.
This action as much as any put us squarely in the realm of any other
mundane agency doing business with the government and did away with the
last vertiges of 'a new institution enthusiasm'.

In this odyssey of the development of our school, there are many lessons.

However bitterly opposed, the selection of a site away from the city
center was correct and has allowed much development as the city has
grown. It was a visionary and responsible step.

However bitterly fought, the enactment of a special taxing agency by
3 very courageous county commissioners was farsighted and has brought
immense benefit to the community in terms of economic growth and
medical development.

However good a new institution may be for a community, it cannot be
established well unless the community fully understands what is
involved. We did not do a good job at all of informing San Antonio what
a school would mean or to integrate ourselves with the community in
general.

However correct one might be in assessing the prior health system in
a community, one cannot malign it publicly and expect the same public to
support the maligner.

However correct one might be in views as to the allotment of patient
care services to given departments or divisions one cannot ignore the
fact that those who perform well will be asked to do so regardless of
affiliation. There is no law that says a designated practitioner is
best because of his title or department.

However well-meaning an administrative decision may be in terms of
'protecting' an institution or individuals, the failure to recognize an
issue as with the pediatric intensive care unit nurse for what it was -
suspected child abuse and to act on that fact promptly - will almost
always be found out and cause unbelievable accusations.

However secure one may feel in one's practice and procedures, one
must always be aware of the fact that any single person can destroy the
work of many over much time for personal gain. In the case of this
school's fine by the government an angry employee, denied a promised pay
raise, profited by 15% of the money paid and caused us no end of trouble
extending over 5 years.

The foregoing lessons are evident in development in the school. In this
ongoing story, there is much that is praiseworthy. There has also been
much to learn. The shortcomings have, in my opinion, largely arisen
from arrogance and lack of common sense. In spite of those
considerations, we have come far.